A53-50 Gastric Bleeding From Mucosal Tear Limitations in Treatment and Interventions

Abstract Intro Upper gastrointestinal bleeding is a potentially life-threatening condition of which endoscopy remains a mainstay for diagnosis and potential treatment. Treatment remains limited when bleeding occurs below the gastroesophageal junction, or in the gastric body. Even with high-risk procedures such as the Sengstaken-Blakemore tube, mortality remains high amongst these patients. Case A 67 year-old male patient with decompensated hepatic cirrhosis secondary to MASH (complicated by recurrent pleural effusions and ascites, hepatic encephalopathy), and non-Hodgkin’s lymphoma was admitted to the ICU for hematemesis and hypotension. Esophagogastroduodenoscopy (EGD) revealed grade III esophageal varices with bleeding requiring banding x2, following which the patient was placed on an octreotide drip. Overnight, the patient experienced recurrent hematemesis with hypotension despite being on vasopressors. He was not a candidate for TIPS by interventional radiology, thus had repeat emergent EGD which revealed non-bleeding protruding grade III varices in the lower third of the esophagus with a new actively bleeding mucosal lesion, consistent with tear within the gastric body. This was treated with epinephrine injections, x3 endoclip placements, and gold probe cautery with hemostasis. He also required massive transfusion with 8 RBC, 1 platelets, 2 fresh frozen plasma. A few hours later, he developed escalating pressor requirements and frothy bleeding around the ETT tube suggestive of reactivated GI hemorrhage. He continued to be hypotensive despite being on multiple vasopressors and was transitioned to comfort care. Discussion Upper gastrointestinal bleeding is a common gastrointestinal emergency that carries significant morbidity and mortality. Resuscitative intervention consists of blood transfusion, PPI, and urgent endoscopic assessment and intervention, all of which our patient received; however treatment remains limited if bleeding occurs below the gastro-esophageal junction. Our patient had recurrent hematemesis from a new gastric mucosal tear, not present on prior EGD. He had multiple unfavorable prognostic factors, namely, 2 concomitant illness, unfavorable site of bleeding, signs of severe bleeding (hematemesis), active bleeding during endoscopy, and hemodynamic instability. The patient was not a candidate for TIPS, and a Sengstaken-Blakemore tube has a limited role in gastric bleeding. Furthermore, Sengstaken-Blakemore tubes carry a high risk of serious complications and risk of re-bleeding even after being deflated up to 50%. Other potential therapies include propranolol, tranexamic acid, and earlier surgical evaluation, but further development and therapies are needed in treatment of bleeds below the gastroesophageal junction. This abstract is funded by: None